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Psychiatry Clerkship

Ziad Kronfol, M.D., Course Director
Deema Al-Sheikhly, MRes, Clinical Curriculum Coordinator

1. Overall Goals
   1. A fundamental understanding of psychiatry as a medical specialty.
   2. A basic working knowledge of psychopathology, psychiatric emergencies, and treatments.
   3. The ability to perform a competent basic psychiatric diagnostic interview.
   4. The ability to formulate a psychiatric differential diagnosis, problem list, and initial treatment plan.
   5. A current view of psychiatric practice.
2. Specific Objectives
   1. To understand psychiatry as a medical specialty that diagnoses and treats disorders of the brain and mind, affecting behavior, perception, emotion, thought, and judgment. Specifically, that:
      1. most psychiatric disorders result from brain dysfunction interacting with psychological stressors and the social environment
      2. account for a large proportion of morbidity in the general population and medical populations
      3. can be successfully treated by medication, psychosocial therapies, or both.
   2. To acquire a fund of basic psychiatric knowledge including:
      1. Psychopathology: Familiarity with DSM IV criteria for major adult and childhood illnesses. Principles of natural history, treatment response, and theories of etiology. Differential diagnoses of common presenting psychiatric symptoms.
      2. Knowledge of what constitutes a psychiatric emergency and the indications for psychiatric referral and/or consultation.
      3. Pharmacologic and psychotherapeutic treatments.
   3. To conduct a competent psychiatric workup, with emphasis on the psychiatric interview as the primary method of information gathering. This requires the student physician to:
      1. engage the patient with an appropriate professional stance and establish rapport
      2. take a complete psychiatric history, including relevant mental and behavioral symptoms, family history, psychosocial function, and medical history.
      3. conduct a complete mental status examination by making accurate observations of pathological behavior and mental phenomena, and inquiring into areas that may not be spontaneously revealed.
      4. appropriately probe sensitive issues such as hallucinations, delusions, suicidal and homicidal ideation, drug and alcohol use, history of abuse and sexual history
      5. manage patients’ emotional responses during the interview.
   4. To formulate a psychiatric case using:
      1. the DSM IV multiaxial system, which incorporates, the psychiatric differential diagnosis, relevant medical conditions, psychosocial stressors, and level of function.
      2. a problem-based approach based on assessments of acuteness, severity, functional impact, and potential for harm
      3. develop and help execute an initial treatment plan.
   5. To acquire, by active participation in the workup and treatment of inpatients and emergency room patients, experiential knowledge of current psychiatric practice, so as to inform career decisions.

The above goals and objectives are achieved by the following three guiding principles of medical student education:

1. Clinical involvement.

   This is a hands-on clerkship. Your objective is to develop a professional rapport with your patients, know them well, particularly their histories, and mental statuses and, under appropriate supervision (see details below), be directly involved in their care. Students may feel at times that they lack the expertise to participate actively in their patients' care and instead are intruding on their patients' private lives. It is usually the opposite which is true, that your patients receive better care because of your involvement. Thus, your role benefits you and your patients.

2. Clinical responsibility.

   You will function as a member of the clinical team by carrying out the jobs that are delegated to you by your Residents, and Consultants (details of this below in the sections describing the clinical components of the clerkship). Most of these jobs will be educational for you, but some (e.g., drawing blood) will be asked and expected of you in your role as a member of the clinical team who already has certain skills. In general, the guiding principle is: you get out of the experience as much as you put in.

3. An academic approach.

   In addition to the required clerkship textbook (see section on readings below), you are expected to read in greater depth about your patients' specific problems and apply what you read to their cases. As a first step, consult the general references on the clerkship reading list (below). Next; search the literature. Med Line and Psych Lit. are two on-line data bases that index virtually all the journals you may wish to consult.

Inpatient Units

Each of you will be assigned to the inpatient unit at the Psychiatric Hospital with opportunities to do psychiatric consultations at HMC, to familiarize yourself with the substance abuse clinic, the Geriatric ward at Rumeillah Hospital and Shafallah Hospital for the developmentally challenged. Generally, you are expected to be at the Psychiatric Hospital from 8:00am-4:00pm Sunday-Thursday except during the scheduled rounds and didactic sessions outside the hospital.

Your clinical work will be the core of your experience here. Team leaders will assign each of you 2-3 patients to follow. You will pick up new admissions as they are admitted to your team. You are expected to WRITE A MINIMUM OF THREE CASE HISTORY ADMISSIONS over the course of your clerkship rotation. The case history is the classic, thorough write-up that you have been trained to do. An outline for this is in the syllabus. In addition, you are expected to write progress notes on each of your patients daily for the first week, and at least three times a week after that.

Additional inpatient responsibilities include:

• Morning round attendance/participation: meet with your patients daily, know their psychiatric and medical history, present findings at rounds
• Present patients at Case Conference
• Obtain literature relevant to treatment of specific patients on the unit
• Participate in individual and family interviews

There are a variety of didactic experiences scheduled for you during your clerkship rotation. Please refer to your Student Schedule for the day-to-day listings. Where possible, didactics are scheduled to avoid conflicts with morning rounds and other Unit or Department activities.

All students take ER calls to gain exposure to emergency assessment of psychiatric problems. Students will be on ER call a total of three weekdays from 4pm-10pm and one weekend from 8am-7pm.

Daytime admissions with the resident are peak educational experiences, so it is critical to coordinate them with your resident. Therefore, daytime admis¬sions take prece¬dence over ALL other sched¬uled activi¬ties such as Grand Rounds, conferences, and didactic sessions. The only exception is if you are paged for an admission when you have already begun participating in your Case History Class or your Interview Class. In that case, tell your resident you will join them immediately after class, and remain in class. Admissions which are begun before those two classes take precedence over the classes. You should continue the admissions, but you must notify the instructor of your absence.

Daytime admissions consist of taking the history from the patient and any family or friends who accompany him or her to the hospital, examining the patient (both physical and mental status exams [see Appendix for MSE format]), discussing the case with the staff, writing orders, and the write-up.

The write-ups has the familiar structure of ID, CC, HPI, PH, FH, Personal (Social) Hx, R.O.S., P.Ex., and MSE. You should conclude your write-ups with a brief (one or two sentence) narrative summary, a differential diagnosis using DSM IV criteria on Axes I through V, and a list of problems and the corresponding plans. End with a discussion of the differential diagnosis, the patient’s problems, and the treatment approaches you are considering. Discuss anything that is unusual or particularly interesting to you about the case. These write-ups will be entered onto the hospital permanent records. All your write-ups must be co-signed by specialist or consultant.

• Present your cases in rounds the next day.
• See your patients daily. The agenda for your "sessions" will come directly from your problem list constructed for your admission write-up.
• Write problem-oriented ("SOAP") progress notes for each day you see the patient.
• Become actively involved with your patients and resident; participate in rounds with your specialist and meet with him or her at least three times a week for a focused review of your patients and assign¬ment of jobs for you to do on each case.

You will be provided with diagnostic equipment which you will need to do for physical exams, which are part of the admission workup and needed when patients have any physical complaints).

There are four levels of supervisors on the clinical services:

1. The Tutor
   These are your WCMC-Q faculty and responsible for the overall teaching and education that you get.
2. The Consultants
   These are the Consultants at the Psychiatric Hospital and responsible for the overall education and clinical care at the Psychiatric Hospital.
3. The Specialists

   These are the direct supervisors of the residents and responsible for the day-to-day management of the psychiatric patient.

4. The Residents

   These are physicians in training in the field of psychiatry while they do provide the bulk of the clinical care, their work is still supervised by certified psychiatrists.

The Resident is expected to:

1. Involve you in the treatment of at least two of their inpatients. You should have the opportunity to see patients with these residents and fellows, and, at times, to see patients on your own and report back to them. Use your contacts with your resident to ask questions about your patients, discuss the rationales for diagnostic and treatment decisions, and for the resident to delegate specific clinical jobs to you, such as: agendas for your meetings with your patients, tests/labs to order or check, family or other doctors/therapists to contact for history or disposition planning, joining a family meeting, etc.
2. Review and give feedback on your progress notes and admission write-ups; refer to your notes in their own notes; supervise and countersign any orders you write.

Your daytime on call: You will be on call during the day with your resident when he or she is on call during the day. You should take 3 inpatient calls with that resident. (If your resident has more than 3 on-calls during your rotation, you do not have to do those).

Rationale: The purpose of inpatient call is to increase the spectrum of psychopathology encountered.

Your evening on-call begins at 4:00 p.m., or immediately after your scheduled activities are over. Your call period extends to 10:00pm on weekdays and 8:00 a.m. to 7:00pm on weekends. You are on call with a resident for the en¬tire time and you are expected to write up the first two ad¬mis¬sions that night. You also participate in, but don't write up, all other admissions until you leave. Keep abreast of call schedule switches by the residents and stay with your resident.

Supervision: Your specialist will:

1. Closely coordinate the workup with you for the first two admissions that night. This should include allowing you to do some of the interviewing and order writing.
2. Discuss the case formulations and write-ups of these two patients with you.
3. Re¬view and countersign your write-ups of these two patients.
4. Involve you in the workups of any other patients after the first two as time permits, but not require you to do the write-ups.

The doctor-patient relationship is protected by confidentiality in all fields of medicine. In psychiatry we are especially careful to preserve the confidential nature of our patients' communications and identities. Take care not to mention patients by name or identify them in any way while in public places, including hospital elevators, corridors, etc…

On the inpatient service the party to the confidential relationship with the patient is the treatment team. No one member of the team should have a confidential relationship with a patient that excludes other team members. A patient might ask you to accept an important piece of information about them, but not share it with anyone else, i.e., a secret. Do not accept secrets. Explain to patients who offer this that, for their welfare, you must be free to share any and all information with your resident, attending, and other members of their team.

Chart notes should be written bearing in mind that the medical record can no longer be considered confidential. Many third parties may request the entire record, as can the patient. Thus, notes should be written informatively, but with restraint concerning details that might compromise the patient or a family member. No other patients should be identified in the medical record.

1. Clinical evaluations by your inpatient consultant, specialist, and course tutors count 55% of your overall grade. Each is weighted according to the proportion of time spent in each clinical component of the rotation.
2. Case History Course - 10%
3. Interview Course - 10%
4. Written exam -- consists of approximately 60 multiple choice questions on the last day of the rotation; counts 12.5% of your final grade.
5. Oral exam -- a one hour interview, presentation, and discussion of a patient with an attending physician. Given during the last week of the rotation. Also counts 12.5% of your final grade.
6. Overall final grade and narrative: Your final grade is determined by the weighted average of the grades submitted by your tutors, inpatient consultants and specialists, your class participation, and your exam grades. Dr. Kronfol writes a composite narrative evaluation of your performance integrating all the narratives received from your tutors, consultants and specialists. This composite evaluation is forwarded to the Associate Dean for Student Affairs office.